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Insurers Now Required by CMS to Conduct Audit for ACA's Risk Adjustment Program

Posted April 6, 2016 (Updated Oct. 3, 2016)

Note: Letters were mailed to select Providers in late August 2016.

Starting in 2016, the CMS requires an annual Initial Validation Audit (IVA) to ensure accurate data is used when assessing the payment transfers for the ACA’s Risk Adjustment (RA) program. Therefore to comply, BCBSIL is asking for the cooperation and participation of all of the independently contracted providers in its network for the required IVA.

Since insurers are required to hire an independent auditor to perform the requirements of the IVA, BCBSIL will be working with Tactical Management Incorporated (TMI) to retrieve medical records. The RA program applies to all ACA compliant individual and small group plans, including plans that are available on and off the Exchange, and conducts a calculation based on enrollee risk. As you are aware, enrollee risk is calculated based on the diagnosis codes submitted on a claim, as well as through supplemental code capture through medical record review. As BCBSIL independently contracted providers, you may be asked to provide medical records directly to the auditor in order to validate all of the diagnosis codes used in the RA calculation within the time frame requested. The IVA requires medical records in order to validate the claims data to CMS on an annual basis. It is of utmost importance that you respond to these requests timely.

The IVA will be performed on a sample of enrollees enrolled in ACA compliant plans. Again, this includes individual and small group plans, both on and off the Exchange. The IVA auditor will seek to validate medical claims of the sampled enrollees from the previous year. For example, this audit will be conducted in 2016, but will review mainly claims with dates of service in 2015. Please be aware some of these claims may have been paid in 2016 and are likely to be included in the sample.

We understand that this is a very busy time. However, in an effort to complete the audit, we appreciate your full support and cooperation as you receive requests from TMI and delivery of the medical record(s) in a timely manner. We want to ensure that the valuable care that you provide to your patients every day is accurately reflected in the data that you provide to auditors for CMS records.

Additional information will be provided in the upcoming months. If you have any questions, please contact your assigned PNC.